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Full text of "United States Navy Medical News Letter Vol. 25, No. 2, 21 January 1955"

NavMed 369 




Vol. 25 Friday, 21 January 1955 No. 2 



TABLE OF CONTENTS 

Residency Training Policy 2 

Antibiotics for Prevention of Rheumatic Fever 3 

Familial Intestinal Polyposis 5 

Congenital Afibrinogenemia 7 

Triopathyof Diabetes 10 

Chemical Control of Cancer 11 

Spontaneous Subarachnoid Hemorrhage 13 

Smooth Muscle Tumors of the Stomach 15 

Intramural Hematoma of the Duodenum 16 

Treatment of Enuresis in Female Children 17 

Methanol Poisoning 20 

Lichen Planus 21 

American College of Chest Physicians 23 

"Just One Letter" 24 

Training Course in Special Weapons, Isotopes, and Military Medicine ... 25 

From the Note Book , 25 

Board Certifications .29 

Correction 29 

NavMed-F Card on Each Patient (BuMed Notice 6-310) 30 

Change Orders to NOy Contracts (BuMed Inst. 7302. 3) 30 

Completion of Part IV, Hospital Staffing Report (BuMed Notice 6320). . 30 

Completion of Part II, Staffing Report (BuMed Notice 6320) 31 

Special Treatment Hospitals (BuMed Inst. 6320. 5D) 31 

Pest Control (BuMed Inst. 6250.4) 32 

PREVENTIVE MEDICINE SECTION 

Traffic Accident Reduction 32 Supplied Sandwiches 37 

Film - "Drive Right" 36 Enteric Carriers 38 

Dispensing Bulk Milk 37 Chlorine Tests on Water 38 

Errors in Use of Insecticides 39 



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Medical News Letter, Vol. 25, No. 2 



Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical De- 
partment of the Regular Navy and Naval Reserve to timely up-to-date items 
of official and professional interest relative to medicine, dentistry, and 
allied sciences. The amount of information used is only that necessary to 
inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
susceptible to use by any officer as a substitute for any item or article in 
its original form. All readers of the News Letter are urged to obtain the 
original of those items of particular interest to the individual. 

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Notice 



Due to the critical shortage of medical officers, the Chief, Bureau of 
Medicine and Surgery, has recommended, and the Chief of Naval Personnel 
has concurred, that Reserve medical officers now on active duty who desire 
to submit requests for extension of their active duty for a period of three 
months or more will be given favorable consideration. 

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Residency Training Policy for 
Reserve Medical Officers on Active Duty 



The response by Reserve medical officers to the Residency Training 
Program for Reserve officers, as provided in BuMed Instruction 1520.7, 
has been most gratifying. There are several vacancies remaining in the 
following residency programs : Pathology, Orthopedic Surgery, Obstetrics 
and Gynecology, Pediatrics, and Urology. A very. limited number of billets 
are still available in Otolaryngology, Anesthesiology, and Ophthalmology. 
While applications for training in the above specialties should be for one 
year at a time, it is expected that in most instances officers who partici- 
pate in this program will be permitted to complete their required training 
without interruption. Every effort will be made to accomplish this insofar 
as service needs will permit. 

Reserve medical officers on active or inactive duty, who have com- 
pleted their obligated active duty imposed by the Universal Military Train- 
ing and Service Act, as amended, are eligible for participation in this 
program. Reserve officers on inactive duty must request return to active 
duty in order to be assigned to such training. 



Medical News Letter, Vol, 25, No. 2 



3 



Eligible and interested medical officers should make applications 
to the Bureau of Medicine and Surgery, via the chain of command. Letters 
of application should contain an agreement to volunteer for the period of 
residency training requested and to remain on active duty in the Navy for 
a period of one year following completion of training, for each year of 
training received. 

From time to time the list of medical specialties in which shortages 
exist will be published in the Medical News Letter. (ProfDiv, BuMed) 

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Antibiotics for Preven tion of Rheumatic £ ever 

The intelligent and judicious employment of chemotherapeutic agents 
should make rheumatic fever prophylaxis feasible and practical. The effi- 
ciency of such prophylaxis depends upon an intimate knowledge of the 
relationship of the streptococcus to the natural history of rheumatic 
fever and upon a thorough understanding of the principles of the chemo- 
therapy and chemoprophylaxis of streptococcal infections. In this article 
some of these principles are reviewed and several methods are evaluated 
which have been used successfully to reduce the incidence and morbidity 
of the disease. 

Two effective approaches exist for the prevention of rheumatic fever 
by the use of antibiotics. The first is protection of the highly susceptible 
rheumatic subject from repeated attacks of the disease by maintaining 
continuous chemoprophylaxis against new streptococcal infections. The 
second is prompt and adequate treatment of streptococcal pharyngitis in 
the general population to reduce the incidence of first attacks of rheumatic 
fever. Each approach is based upon different considerations and is dis- 
cussed separately. 

Despite the rudimentary state of knowledge of the pathogenesis of 
rheumatic fever, some general principles have been formulated for the 
prevention of recurrences. The attack rate of rheumatic fever in the 
general population following streptococcal pharyngitis has been estimated 
to be about 3%. In patients who have suffered a recent bout of rheumatic 
fever, this attack rate has been reported to be as high as 50% From sero- 
logic and bacteriologic studies, it is known that subclinical streptococcal 
infections are frequent and can initiate new attacks of rheumatic fever. 
It is generally agreed, therefore, that the highly susceptible rheumatic 
subject must be continuously protected against streptococcal exposure 
and that for such patients it is unsafe to await clinical signs of upper res- 
piratory infections before initiating antibiotic prophylaxis. 

The decision as to how long prophylaxis must be maintained is a 
matter to be determined by individual circumstances. Certainly it would 



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Medical News Letter, Vol. 25, No, 2 



seem wise to protect the rheumatic fever patient for at least the five-year 
period following a rheumatic attack during which the recurrence rate is 
known to be highest. This period should be extended for the young rheu- 
matic subject. It would be unwise to discontinue protection if after five 
years the patient is still of elementary or secondary school age- -the 
period of highest incidence of streptococcal infections. Similarly, pro- 
phylaxis may have to be maintained longer if the rheumatic subject attains 
the age of eighteen but is exposed to an environment in which the risk of 
streptococcal exposure is high. This is particularly true when rheumatic 
heart disease is present. 

Limited data are available upon which to base recommendations for 
the adult rheumatic cardiac. The frequency of streptococcal infection and 
rheumatic recurrences in this age group is not well documented. It is 
known, however, that rheumatic recurrences may occur at any age and 
it is well to weigh the possible disastrous consequences of a new attack of 
rheumatic fever in a patient with severe rheumatic heart disease against 
the expense and inconvenience of maintaining such patients upon antibiotics 
continuously. It has been recommended that all patients with rheumatic 
heart disease on the wards of general hospitals receive chemoprophylaxis 
against streptococcal exposure. Extension of such protection beyond the 
hospital environment appears reasonable. 

It is not yet known whether the attack rate of rheumatic fever follow- 
ing streptococcal infection will be diminished after continuous prophylaxis 
is maintained for several years. Until more information becomes avail- 
able as to whether susceptibility to rheumatic attacks "wears off" with 
periods of freedom from streptococcal infection, it is difficult to limit 
the duration of continuous prophylaxis arbitrarily. 

The selection of patients for continuous chemoprophylaxis should 
logically include all who have had a recent well defined attack of rheumatic 
fever. This selection cannot be made solely on the basis of age, severity 
of the attack, or limitation of the overt disease process to the joints or 
central nervous system. The disease is recurrent in the older as well as 
the younger age group. An initial mild attack may be followed by a second 
bout of severe crippling, even fatal, carditis. A rheumatic career begin- 
ning with Sydenham's chorea may end with advanced rheumatic heart dis- 
ease. 

The decision to start prophylaxis for a period of years is a serious 
one and involves the possibility of causing psychic trauma, and even in- 
validism, unnecessarily in individuals who are not really rheumatic. At 
the risk of failing to recognize some rheumatic subjects, it is best to 
reserve prophylaxis for those whose diagnosis is firmly established. 
Before instituting small prophylactic doses of antibiotic to prevent new 
streptococcal infection, it has been considered advisable to administer 
a course of penicillin therapy adequate to eradicate the streptococcal 



Medical News Letter, Vol. 25, No. 2 



5 



carrier state as soon as the diagnosis of rheumatic fever has been made. 
The absence of clinical signs of pharyngitis and the failure to culture 
group A streptococci from the nose or throat may not always exclude the 
presence of these organisms deeper in the tissues, particularly in the pres- 
ence of enlarged tonsils. 

The peak incidence of rheumatic fever in the United States usually 
occurs in the spring; the lowest point in the late fall. Sporadic and even 
epidemic streptococcal infection can occur at any season, however, so 
that prophylaxis should be maintained throughout the year. 

It is apparent that the major limitation of the chemotherapeutic 
approach to the prevention of rheumatic fever is the difficulty of clinical 
identification of streptococcal sore throat. To avoid the promiscuous and 
unnecessary administration of penicillin to patients with viral and non- 
streptococcal upper respiratory infections, the clinical criteria for the 
diagnosis of streptococcal pharyngitis should be more widely recognized. 
Simple coryza, cough, hoarseness and tracheitis are rarely due to strep- 
tococci. The syndrome of sudden onset of fever, sore throat, "beefy" 
redness of the pharynx, and pharyngeal exudate suggest the diagnosis. 
Cervical lymphadenitis and the presence of leukocytosis add further evi- 
dence for it. In a recent large series of patients studied, a proper diag- 
nosis was made on clinical criteria alone with 70% accuracy. 

Because the preceding streptococcal infection may be unapparent in 
at least 38% of patients in whom rheumatic fever develops, it is obvious 
that the chemotherapeutic approach will prevent, at best, little more than 
half of the total cases. The proper diagnosis, treatment, and control of 
streptococcal infections may reduce their prevalence and this could be 
reflected in a further decline in the incidence of rheumatic fever. 

The use of antibiotics in the prophylaxis of rheumatic fever is far 
from an ideal solution of the problem. Pending more knowledge and a 
better approach, however, the incidence and morbidity of the disease can 
be reduced significantly by appreciation on the part of physicians and the 
general public of the importance of early diagnosis and proper therapy of 
streptococcal disease and upon diligent protection of rheumatic subjects 
from streptococcal infection. {Am. J. Med. , Dec. , 1954; G. H. Stollerman, 
M. D. , New York University College of Medicine, New York City) 

****** 

Familial Intestinal Polyposis 

Familial intestinal polyposis is a rare hereditary disease character- 
ized by the growth of many adenomatous polyps from the rectal and colonic 
mucosa. The polyposis generally develops in adolescence or early adult 
life, though more rarely it may occur in the first decade or after middle 



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Medical News Letter, Vol. 25, No. 2 



age. The disease appears to be inherited as a heterozygous, dominant 
Mendelian characteristic; thus, only an affected parent, either male or 
female, can transmit the disease, and then only to half the children. 
Colonic polyposis is probably the most clearly defined precancerous 
disease known to medical practice today. 

Familial polyposis of the colon should be differentiated from con- 
genital polyposis affecting the whole gastrointestinal tract, a disease 
which is accompanied by skin pigmentation. The obvious skin marking 
and the early obstructive symptoms from the benign polyps of the small 
intestine soon bring such patients for medical advice, whereas the symp- 
toms of polyposis of the large bowel may be relatively trivial until malig- 
nancy supervenes. Isolated polyps in the rectum are not uncommon and 
should not be confused with colonic polyposis, in which the polyps are 
much more numerous and widespread. If an adult is seen to have a few 
polyps only on sigmoidoscopic and x-ray examination, the case should 
not immediately be diagnosed as one of colonic polyposis. 

How the disease originates in a family is not understood. This 
article discusses the various problems that arise during the investigation 
of families affected by familial polyposis. Two families in particular are 
reported. Fifty-five polyposis families were investigated and the family 
pedigrees prepared. The families include 1036 members, using the word 
"member" to describe polyposis patients,"" their brothers and sisters, and 
the direct descendants of these persons. Of these 1036 members, no few- 
er than Z08 are known to have suffered from polyposis, and 150 have already 
developed intestinal cancer. 

The growth of the intestinal polyps is generally far advanced before 
a patient seeks medical attention because of his symptoms. The incidence 
of cancer in these persons is distressingly high; in a series of 45 patients 
undergoing colectomy, C. W. Mayo found that only 6 were free from cancer 
and that, in many cases, there was more than one focus of malignant dis- 
ease. In nearly all cases, a careful histological search throughout the 
colon and rectum will show areas of great epithelial hyperplasia, which, 
although there is no invasion or gross irregularity of cell architecture, 
can be but a short step from frank carcinoma. 

Diarrhea is the earliest symptom of the disease and at the outset may 
be very slight, amounting to little more than a soft consistency of the 
feces. The insidious progression of this symptom is not noticed by the 
patient who comes to think that it is normal for him to have more frequent 
bowel actions than his fellows. Late in the disease, the diarrhea increases, 
interfering with the patient's daily life, while hemorrhage and mucous dis- 
charge from the polyps give rise to symptoms which cannot be disregarded. 

The clearing of the rectal polyps by fulguration is generally best done 
before colectomy, as afterward the ileal content tends to obscure the 
rectal mucosa. The anastomosis between the ileum and the remaining 



Medical News Letter, Vol. 25, No. 2 



7 



large bowel must be within reach of a sigmoidoscope; the higher the anas- 
tomosis, the easier it is to perform and the more normal the postoperative 
bowel function is likely to be. These advantages of the ileosigmoid and 
high ileorectal anastomosis over a lower ileorectal anastomosis are offset 
by the larger area of mucosa left in situ from which new tumors may arise 
and the greater difficulty that their fulguration will present. In more severe 
cases the rectal polyps may be so numerous that fulguration of all of them 
will leave the rectum so scarred or stenosed that its function will be im- 
paired. In these cases the only alternative to excision of the rectum and 
establishment of a terminal ileostomy is to remove the whole rectal mu- 
cosa, leaving the muscular wall of the rectum and passing the terminal 
ileum through this muscular tube to anastomose it to the anal mucosa. This 
operation has the advantage of removing all the tumor-bearing mucosa, but 
it has not yet been fully established that this anal ileostomy is controlled 
by the preserved sphincters adequately enough for the patient to lead a nor- 
mal life. 

In a disease of this type, one would expect that the members of the 
affected family would be very willing to take medical advice and cooperate 
in being examined, as the majority of them must be aware that, in ignoring 
this advice, they are running the risk of developing a lethal disease at a 
relatively early age. Unfortunately, this is not always the case, and it 
is often more difficult to persuade members to be examined than to trace 
them after they have lost touch with their family. The two main reasons 
for this are the fatalistic attitude which the family members tend to adopt 
toward the disease, sometimes amounting' to a denial that the disease 
exists or that it can affect them personally, and their fear of treatment 
which they associate with colostomies and failure to cure their older rel- 
atives. 

Ideally, all members of the family should be traced, and those who 
may possibly inherit the disease should be examined at intervals until they 
are past the age when the disease is likely to develop. The wholehearted 
confidence and good will of the family is needed to achieve this ideal; with- 
out it, the good intentions of the enthusiastic doctor are likely to be thwart- 
ed by obstructive tactics, if not by open opposition. (Arch. Surg., Dec., 1954; 
P. H. Brasher, M. B., Saskatoon, Sask., Canada) 

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Congenital Afibrinogenemia 

The complete congenital absence of fibrinogen is apparently one of the 
most unusual anomalies; only 21 cases have been reported to date. In this 
presentation the 22nd patient is discussed and a brief review appended. 
Aside from their rarity, these patients present findings which throw light 



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Medical News Letter, Vol. 25, No. 2 



on other, commoner problems and are examples of conditions which are 
impossible to produce experimentally at present. 

The authors have been able to locate 18 reports of 21 patients with 
congenital lack of fibrinogen. The outstanding abnormality common to 
this group, and present in no other disorder that they were aware of, is 
complete incoagulability of the blood from birth. Absence of fibrinogen 
is a feature of all except the patient of Castex and co-workers in which it 
is said to be present in trace amounts. Fifteen of the 22 patients are 
males. Cousin marriages appeared in the kinship of 7 of the patients, 
occurring in parents or grandparents. Seven had siblings with bleeding 
disorders, although only the cases of Diamond and co-workers were 
proved to be of afibrinogenemia. In four reports, hypofibrinogenemia 
existed in one or more relatives of the patients. In others, where de- 
termined, parents and siblings had normal fibrinogen levels. Variable 
results were obtained from estimations of capillary fragility. Bleeding 
phenomena have been noted from an early age, most of them from birth, 
and bleeding was the cause of death in 5 of the 8 who were dead at the time 
of the last report. It is surprising to note that these patients have less 
bleeding difficulty on the average than many patients with hemophilia, des- 
pite the complete incoagulability of their blood. Bleeding has been assoc- 
iated with the eruption and shedding of teeth, trauma, diphtheria, tuber- 
culosis, and surgery. There has been a variable association with low 
platelet levels, often unassociated with bleeding. Despite the lack of a 
fibrin net, healing of wounds has not been retarded. The bleeding time 
has been widely variable in these patients. The sedimentation rate of 
the blood has been low in the 10 cases in which it was mentioned. The 
prognosis is difficult to give because of the small number of patients re- 
ported, but seems to be poor on the basis of present data, with 8 of the 21 
dead, and the oldest reported to be alive at 20 years of age. However, it 
is to be expected that the survival rate will improve as transfusion tech- 
niques have improved. It is likely, as mentioned by Henderson and co- 
workers, that many others with this condition have died from umbilical 
hemorrhage at the time of birth without diagnosis. Pulmonary tubercu- 
losis occurred in 2 patients. Despite the lack of fibrinogen, Prentice's 
patient had fibrous pleural adhesions but no fibrin in the tuberculous gran- 
ulomas. The patient of Castex and co-workers had a tuberculous infection 
of the "primary" type and was given plasma in the hope that the fibrinogen 
therein would facilitate arrest of the process. In the short period the pa- 
tient was observed up to the time of their report, no effect could be demon- 
strated. 

The small number of cases reported makes sweeping conclusions all 
but impossible. The onset immediately after birth might be expected in 
a congenital defect and is analogous to hemophilia. There are insufficient 
cases to indicate which sex predominates, but the 7 girls make it a non- 
sex-linked recessive. Present evidence does not indicate the existence 



Medical News Letter, Vol. 25, No. 2 



9 



of a less severe degree of the defect in other members of the families. 
Several racial strains are implic ated- -Northern European and Semitic. 
Associated developmental anomalies are not common, only 1 patient in 
this group having one (harelip and cleft palate). 

On'e of the most interesting facets of the disorder is the apparent 
lower degree of morbidity, though not of mortality, when the disorder 
is compared with hemophilia, despite the complete incoagulability of the 
blood--a finding never observed in hemophilia. 

The question of absolute absence of fibrinogen is unsettled. Various 
means have been used to establish the levels: salting out with sodium 
chloride and ammonium sulfate, heating to 56 C, microscopic observa- 
tion and serological tests, electrophoresis, and addition of concentrated 
thrombin solutions. 

Present facts offer no pathogenesis for the disorder, except for the 
evidence that .it is sometimes apparently genetically determined. No 
functional or morphological lesion other than the main defect is apparent 
with present methods. 

The differential diagnosis is reasonably straightforward. When the 
absence of clotting is determined, hemophilia is ruled out. This may 
be rapidly accomplished by addition of thrombin and should prove helpful 
in newborn males, in whom it is a consideration of importance. If this 
simple procedure is carried out, it is likely that many more instances 
of this disorder will be discovered. Other unusual disturbances of blood 
coagulation are similarly ruled out by the absence of clotting upon addi- 
tion of potent thrombin solution. Hitherto not touched upon, is one of the 
most important conditions which must be differentiated- -the acquired 
form of afibrinogenemia, and the congenital and acquired forms of hypo- 
fibrinogenemia. The few reported instances of congenital hypofibrino- 
genemia have not been associated with incoagulability of the blood. The 
acquired forms of complete and partial absence of the protein may be 
suspected by the nature of their accompanying disease and an onset 
after the neonatal period. 

Treatment is the same as that of hemophilia. Local control of ex- 
ternal bleeding, not associated with shock or anemia, may be sufficient. 
If inaccessible bleeding is present, unassociated with anemia, fresh 
plasma or thawed plasma (frozen while fresh) may be used. Fibrino- 
gen solutions could be used but are not necessary. If shock or anemia 
is also present with internal or external bleeding, fresh whole blood is 
indicated. The cessation of bleeding is prompt, and the effect persists 
for a variable period- -at least 4 or 5 days. (Am. J. Dis. Child., 
Dec, 1954; R. W. Prichard, M. D. , and R. L. Vann, M. D. t Bowman 
Gray School of Medicine, Wake Forest College, Winston-Salem, N. C. ) 



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Medical News Letter, Vol. 25, No. 2^ 



Triopathy of Diabetes 

The term "triopathy" has been applied to diabetic patients who usually 
have shown, first, clinical evidence of neuropathy; then, diabetic retinitis, 
and finally, the nephropathy of diabetes. 

In the series discussed, the term "diabetic neuropathy" has been used 
to include those patients with a history or findings of severe neuritis 
(neuronitis), that is, in whom severe paresthesias, nocturnal pain, objec- 
tive evidences of loss of sensation, of motor function or of reflexes, or 
disturbances in the autonomic nervous system, have been persistent after 
initial or temporary diabetic control has been attained. 

The retinopathy referred to means the presence, not merely of cap- 
illary microaneurysms of diabetes, but of hemorrhages and characteristic 
diabetic exudates. The hard, waxy exudates, with changes in caliber and 
thickened walls of the venules, are features. The more serious retinitis 
proliferans is characterized by the new formation of fibrous tissue, espe- 
cially at or near the optic disc, often as organization of areas of hemor- 
rhage. Separation of the retina and repeated hemorrhage into the vitreous 
occur frequently. 

The diabetic nephropathy is frequently ushered in by albuminuria or 
edema. Within a year or more, the edema may become permanent; hyper- 
tension develops, and retinal lesions, present either before or subsequent 
to the edema, advance. During the first few years of this stage, a neph- 
rotic syndrome with elevated plasma cholesterol values, marked edema, 
and marked albuminuria, may appear benign, but sooner or later a stage 
of nitrogen retention is ushered in and uremia results. 

The discussion of the pathogenesis of the malignant triopathy begins 
with the background of the diabetes itself. Diabetes mellitus is hereditary 
in the sense that the tendency to the development of diabetes is inherited 
and may be manifested in an early period in life or may remain latent 
until the stress of excessive overweight, infection, or local damage, as 
in hemochromatosis, brings it forth. Diabetes mellitus is believed to be 
inherited as a recessive gene. The hypothesis that such an inheritance 
carries with it a special vulnerability of the central nervous system and 
the vascular system, is speculative but is gaining support from many 
studies. Although the hereditary genes may be altered, a second factor 
may well be of equal importance, namely, the influence of the maternal 
environment in utero. In recent years, the influence of this period in the 
life of the embryo has been more and more emphasized since the frequency 
of unusually large babies and the later development of maternal diabetes 
has been studied. 

Diagnosis and treatment of diabetes in its early stages with the early 
use of insulin is of basic importance. Once the sequelae have made their 
appearance, then treatment will yield results which vary with the stage of 



Medical News Letter, Vol. 25, No. 2 



1 1 



the condition. If the neuropathy is recognized early, the syndrome of 
pain in the legs, hyperesthesia, muscular weakness, and atrophy, can 
be brought to an end at periods which may vary from a few weeks to one 
or more years. This treatment consists basically of bringing the diabetes 
under control with diet and insulin. The use of a diet, containing from 90 
to 120 gm. of protein and roughly 1800 to 2000 calories, is started. One 
difficulty is that, during the acute phase of a severe neuropathy the 
appetite is seriously disturbed. Treatment of the Charcot foot is notori- 
ously unsatisfactory. Treatment of nocturnal diarrhea, with incontinence, 
is usually successful with the use of liver injections and adequate control. 
Diarrhea, however, may recur. Spontaneous remissions do occur. Treat- 
ment of retinitis proliferans is unsatisfactory. However, a follow-up of 
a series of some 450 cases of retinitis proliferans showed a considerable 
group of patients, notably those 40 years and over, in whom retinitis pro- 
liferans remained stationary for as long as 5 to 15 years before serious 
loss of vision occurred. In contrast to this group, however, it must be 
admitted that, in the majority of patients with retinitis proliferans, the 
condition progresses to serious loss of vision, nearly complete blindness, 
and in a few cases, loss of one or both eyes from hemorrhagic glaucoma. 

Treatment of nephropathy presents a somewhat similar variable pic- 
ture. During the nephrotic state, when edema and elevation of the plasma 
lipids, including cholesterol and lipoproteins, are present without nitrogen 
retention, treatment by diuretic s, rest in bed, salt restriction, and some- 
times, the cautious use of plasma transfusions will relieve the symptoms. 
Once, however, the state of nitrogen retention has been reached, with ele- 
vation of blood pressure and retinitis, treatment to prevent further pro- 
gression is symptomatic only. (Arch. Int. Med., Dec, 1954; H. F. Root, 
M. D. , Boston, W. H. Pote Jr., M.D., Los Angeles, and H. Frehner, M. D. , 
Herisau, Switzerland) 

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Chemical Control of Cancer 



Satisfactory therapy for most patients with cancer has not been 
achieved. The advances in surgery which permit more extensive opera- 
tions and the increased control of tumors, which can be exerted by the new- 
er techniques and more powerful equipment of modern radiotherapy, still 
fall desperately short of solving the problem. Most physicians are legit- 
imately skeptical that further advances in these two disciplines can success- 
fully cope with the challenge. 

In 195 3, approximately 224,000 people died from cancer in the United 
States. Of all patients with malignant disease, it is probable that only one- 
fourth to one-third are cured today. Full use of present knowledge and 



12 



Medical News Letter, Vol. 25, No. 2 



better methods for earlier diagnosis would surely save more lives. There 
remain, however, millions of persons who will die from cancer in the fore- 
seeable future despite the most informed use of surgical or radiotherapeutic 
procedures, and regardless of the most meticulous attention to diagnostic 
techniques. 

Two investigative approaches could be extended with reasonable hope 
of finding useful clinical applications. The first approach-- studies of car- 
cinogenesis--may elucidate avoidable environmental or endogenous factors 
which, though now unknown, may be responsible for many cancer deaths. 
Recognition and avoidance of certain carcinogenic materials in the. environ- 
ment in the past have diminished their hazard. 

The positive identification of carcinogens is difficult. This difficulty 
may better be appreciated if it is recalled that the identity of the cancerous 
process in all its different types and loci is far from certain; there may be 
as many endogenous carcinogens as there are cancers, and perhaps mul- 
tiple conditions must be satisfied for malignant growth to occur. Despite 
the enormity of the task, the possibility is real that etiological and path- 
ogenic factors can be identified and can then be avoided or counteracted. 
Research in carcinogenesis is deserving of the most intensive studies. 

Chemotherapy of cancer is the second approach which has the poten- 
tiality of effecting a major decrease in cancer mortality. This potentiality 
has not been realized in man; no compound in use or under study at present, 
offers significant promise of producing cure of human cancer. That there 
are systemic agents which alter the course of some malignant diseases is 
a signal achievement worthy of full exploitation. Several drugs in current 
use offer worthwhile benefit to cancerous patients. Close study of these 
agents may promote synthesis of drugs possessing cancerocidal rather 
than cancerostatic action, or discovery of compounds better able to pro- 
vide remission, if not cures. 

Certain characteristics of the several cancer chemotherapeutic drugs 
permit their classification in different ways. Perhaps the broadest of 
these classifications describes the mechanism of action as interpreted 
clinically. Essentially, these drugs may be segregated into (1) those 
agents which chiefly affect the host's response to, or toleration of, malig- 
nant tissue, with a variable degree of effect on the cancer cells, and (2) 
those agents which exert toxic action directly on cancer tissues with a 
variable degree of toxicity in normal host cells. 

The antineoplastic effect of the drugs to be discussed, although not 
cell-specific, is not diffuse nor wholly nonspecific. To a great extent the 
effect is limited to a certain disease or group of diseases. Without major 
exception, those malignant growths which currently can be favorable mod- 
ified by drugs, arise from hematopoietic tissues, lymphoid, and reticular 
tissues, and from some of those organs whose functional status is influenced 
by endocrine control. For the vast majority of individuals with metastatic 



Medical News Letter, Vol. 25, No. 2 



13 



carcinomas, there is no drug of proven value. Many reasons might be 
advanced for the failure of response of carcinomatous cells. Surely 
there are chemical differences between carcinomatous and lymphomatous 
cells. These may involve such factors as the relative degree of variance 
from normal cells, the rate of growth, and the ability to tolerate or adapt 
to modified biochemical environment. 

The drugs of clinical value with current applicability in cancer chemo- 
therapy are: the nitrogen mustard compounds, mechlor ethamine and tri- 
ethylene melamine; the folic acid antagonists, a-methopterin and aminop- 
terin; the purine analog, 6-mercaptopurine ; the hormones, cortisone and 
testosterone; and the estrogenic substance stilbestrol. Note is made of 
adrenalectomy and hypophysectomy, and of some chemical agents of limit- 
ed clinical importance: urethane, myleran, and the ethylene phosphor- 
amides. 

The chemical control of cancer has not yet been realized. Within the 
past 15 years a more profound understanding of cancer has been achieved, 
and several approaches to its treatment with drugs have been reviewed 
in this article. 

Cancer cells are different from their normal counterparts when viewed 
under a microscope. Although it is possible that this difference is purely 
one of rearrangement of the same chemical components within the cell, a 
vast amount of evidence defines at least quantitative alterations in composi- 
tion. Functional capacities of malignant and normal cells of homologous 
tissues may be greatly different. Therapeutic agents which depend on 
these quantitative differences in the metabolism of cellular constituents 
afford promise for future progress. A constant search for qualitative dif- 
ferences between neoplastic and normal cells may elucidate obvious path- 
ogenic or perpetuating mechanisms which can be interrupted. Further, it 
seems within the realm of possibility that pharmacological agents will be 
found that can effectively counteract the etiological factors which lead to 
cancer--be they viral, chemical, or physical exposure; idiopathic muta- 
tion; or a still unrecognized multitude of cellular insults. (Pub. Health 
Rep., Dec, 1954; J. F. Holland, M. D. , Roswell Park Memorial Inst., 
Buffalo, N. Y. ) 

jjs sje ggc $ if ♦ 

Spon taneous Subarachnoid Hemorrhage 

The treatment of spontaneous subarachnoid hemorrhage is based on 
reports in the literature of series of cases. Conclusions drawn from these 
series have been conflicting. A large series of cases, followed in extreme 
detail and analyzed minutely, would be of great help in resolving many 
controversies which have risen out of the inconsistencies reported in the 



14 



Medical News Letter, Vol. 25, No. 2 



literature. However, until this critical series is presented, it would be 
of value to consolidate these reports so that as much information as pos- 
sible may be gained from the available data. This would also point up 
the factors that should be checked in future studies of this type. In this 
presentation the major series of spontaneous subarachnoid bleeding have 
been gathered together and the material presented has been consolidated 
wherever possible so that a more informative result could be obtained. 

The series under discussion has been taken from clinical material 
in which the diagnosis of spontaneous subarachnoid hemorrhage was made 
from the syndrome of sudden onset of severe meningeal irritation, with 
or without focal neurological signs, with bloody or xanthochromic spinal 
fluid, and without indication of underlying conditions, such as blood dys- 
crasia, trauma, syphilis, infections, and neoplasms. 

Spontaneous subarachnoid hemorrhage is a malignant disease, with 
the incidence of death a factor of the length of time from the onset of the 
first hemorrhage. The mortality rate is generally assumed to be between 
40% and 50%, a figure which is valid only for the period from one month 
to one year. Before one month the mortality rate is lower, and after one 
year, it is greater. This additional dimension is of importance in formu- 
lation of the therapeutic program. 

The mortality of subarachnoid hemorrhage falls into two categories: 
cases in which death is due to the first attack, and cases in which the pa- 
tient succumbs to a subsequent bleeding. A great deal of attention has 
been given to the group with subsequent bleeding and many of these people 
can be helped with definitive treatment. The physician is able to offer 
nothing except palliative and supportive treatment to those who die in the 
first attack--a group which represents approximately 28% of all cases 
with subarachnoid hemorrhage. 

Only four of the signs found in this condition are reported in the lit- 
erature in sufficient detail to be analyzed for their prognostic significance. 
These signs are coma, convulsions, hypertension, and papilledema. The 
appearance of any of the first three signs singly, the first two to a greater 
degree than the third, is indicative of a poor prognosis for life. There is 
no data on the prognosis when a combination of these four signs exists, but 
this could logically be assumed to be even a more direful portent. 

A consideration of the relation of the age of the patient at the onset 
of the hemorrhage shows that age has no effect on the mortality rate. 
Approximately 10% of all patients with subarachnoid hemorrhage are 
maimed to a significant degree, in addition to those patients who die. This 
fact should also be considered in any thought on the prognosis of subarach- 
noid hemorrhage. 

It is not clear from the literature just how often there is an aneurysm 
when there is subarachnoid hemorrhage. The best inference is that it 
occurs in about 50% of the cases. This incidence is an important considera- 
tion from the point of view of surgery, for only the cases with demonstrable 



Medical News Letter, Vol. 25, No. 2 



15 



aneurysms, arteriovenous malformations, and tumors, can be treated 
surgically, and not all of these cases can be so treated. Certainly, the 
presence of such a large group, in which the cause of bleeding is not 
found, is an academic and clinical problem of great magnitude. 

A frequent contraindication to surgery is multiplicity of the aneurysm 
which is present in about 13% of all patients that have aneurysms. This 
finding shows that a thorough angiographic study is indicated before surg- 
ical treatment is done. 

Angiomatous malformation was found to be an uncommon cause of 
spontaneous subarachnoid bleeding. (Arch. Neurol. & Psychiat. , Dec. , 19 54; 
S, A. Jacobson, M. D. , New York City) 

jjt sjc ijc i(s $ * 

Smooth Muscle Tumors of the Stomach 



Smooth muscle tumors of the stomach, which include leiomyomas 
and leiomyosarcomas, are not uncommon . The pathogenesis of leiomy- 
omas and leiomyosarcomas of the stomach has been the subject of spec- 
ulation for many decades. Some theories which have been postulated are: 

(1) that the tumor is derived from embryonic rests (Cohnheim); (2) that 
the neoplasm is secondary to an inflammatory process which results in 
an unchecked proliferation of muscle tissue during the reparative stage; 
and (3) that the tumor arises from the smooth muscle of the vessels or 
stomach wall unassociated with inflammation. At present, most auth- 
orities favor an origin from the gastric musculature. 

The symptomatology of smooth muscle tumors of the stomach is 
varied and nonspecific. The location of the tumor is of prime importance. 
If the neoplasm is in the fundus, it may be silent. If the lesion is in the 
pylorus, it may be associated with intermittent obstruction. When ulcer- 
ation supervenes, the most frequent complaints include: indigestion, 
heartburn, epigastric pain, hematemesis, melena, and persistent emesis. 
The duration of the symptoms is variable, being a matter of days to many 
years. When heartburn and epigastric distress are the presenting symp- 
toms, there is usually a long period before the diagnosis is entertained. 

Most cases fall into one of three patterns: (1) the presenting symp- 
toms are hematemesis and melena, or the result of chronic blood loss; 

(2) the chief complaint is epigastric or upper abdominal pain or discom- 
fort; and (3) an abdominal mass is noted by either the patient or the phys- 
ician. The physical findings are usually negative except when there is a 
palpable mass or when the presenting picture is that of hemorrhage. The 
only frequent abnormal laboratory finding in these patients is the presence 
of moderate anemia, usually microcytic, hypochromic in type. 

The clinical diagnosis of smooth muscle tumors of the stomach rests 
primarily with the roentgenologist and gastroscopi st. 



16 



Medical News Letter, Vol. 25, No. 2 



The treatment of smooth muscle tumors of the stomach is solely 
surgical resection, because they are radio-resistant. With leiomyomas, 
the procedures have varied from a submucosal dissection and enucleation 
of the tumor mass to a complete gastrectomy. In most cases a wedge 
resection or a subtotal gastrectomy suffices. Doubtful cases should be 
treated as leiomyosarcomas. For the latter, Marvin and Walters recom- 
mend a subtotal or total gastrectomy. (Ann. Surg., Dec, 1954; E. A. Everts, 
M. D. , and H. L. Kazal, M. D. , Jefferson Medical College Hospital, Phila- 
delphia) 

Intramural Hematoma of the Duodenum 



Intramural hematoma of the intestine is a condition in which, spon- 
taneously or as a result of trauma, a localized collection of blood extra- 
vasates into the subserosal and interstitial tissues of the intestine. It has 
been described on a number of occasions as an unexpected finding at lapa- 
rotomy or at autopsy, but a correct preoperative diagnosis has not been 
recorded. 

The authors encountered four cases in each of which the duodenum 
was predominantly affected. The roentgen findings are so distinctive 
that they are believed to be pathognomonic of intramural hematoma of 
the duodenum. 

Nothing in the symptomatology, physical findings, or laboratory data 
could be considered diagnostic of intramural hematoma. A history of trauma, 
however, or of a bleeding tendency, may suggest the possibility of this con- 
dition. Pain is usually located in the upper abdomen and may be dull, sharp, 
or colicky. It is often associated with nausea and vomiting, but hemate- 
mesis and melena are generally absent. Abdominal examination usually 
reveals upper abdominal tenderness and muscle guarding. Low-grade 
fever and moderate elevation of the white count with increase in poly- 
morphonuclear leukocytes are often present. The red count and hemo- 
globin are usually normal. 

The roentgen diagnosis of intramural hematoma of the duodenum 
should offer no difficulty if a gastrointestinal series is performed and if 
one is familiar with the entity. 

Intramural, extramucosal neoplasm is simulated, but the swelling of 
the mucosa proximal to the main defect, the coil spring appearance, and 
the length of the abnormal segment, make this diagnosis untenable. 

The roentgen appearance may resemble that of an intussuscepting 
mass, but in intussusception, oral administration of barium should reveal 
shortening of the duodenum and visualization of the constricted inner lumen. 
The rare retrograde intussusception can be ruled out by the eccentric 



Medical News Letter, Vol. 25, No. 2 



17 



position of the intramural defect, the lack of shortening of the duodenum, 
and the mucosal changes in the proximal duodenum. 

Other conditions, such as pancreatitis, duodenal infarction, and lymph- 
oma or other malignant tumor, should present no serious problem in differ- 
ential diagnosis if one is familiar with the distinctive roentgen appearance 
of intramural hematoma. 

From the pathological descriptions in the literature, it is probable 
that similar roentgen changes would also be encountered in intramural 
hematoma involving other portions of the small intestine. Unfortunately, 
roentgen descriptions are not available in such cases. In the case of intra- 
mural hematoma of the ascending colon, reported by Kratzer and Dixon, 
an intramural lesion was suggested by the barium enema study. The 
reproductions, however, show no evidence of the coil spring appearance. 

Intramural hematoma of the duodenum has not, heretofore, received 
consideration in the differential diagnosis of the "acute abdomen. " If the 
possibility of this diagnosis is entertained, and if there is no clinical evi- 
dence of bowel perforation or other contraindication, a gastrointestinal 
series should be performed. The demonstration of an intramural extra- 
mucosal mass associated with a coil spring mucosal pattern will establish 
the diagnosis. (Radiology, Dec, 1954; B. Felson, M. D., and E. J. Levin, 
M, D. , University of Cincinnati College of Medicine, Cincinnati, O. ) 

$ * # * * # 
Treatm ent of Enuresis in Female Children 

The etiology and pathogenesis of enuresis are not definitely established 
as demonstrated by the varied theories offered by the numerous contribu- 
tors on the subject in the literature. Obviously, the cause is not the same 
in each child. Enuresis is only a symptom and it is the responsibility 
of the pediatrician, urologist, and psychiatrist to discover the immediate 

cause in each case. 

The importance of correction of the enuretic problem is obvious. It 
is essential for the normal mental development of the child and his accept- 
ance in any society that he be continent of urine. It is important for the 
peace of mind of the parents that their child be normal in this respect. 
It is even more important that this symptom --rather common in children-- 
not be carried into adult life where the individual with enuresis is even 
more a social outcast than he was as a child, and in whom failure to cor- 
rect an organic lesion in the urinary tract may well lead to permanent 
damage. 

Because it is a well recognized fact that enuresis is only a symptom 
of some underlying disease, it is obvious that, as in all other symptom 
complexes, the underlying etiology should be first determined in an attempt 



18 



Medical News Letter, Vol. 25, No. 2 



to decide whether the projected therapy will be treating the underlying 
cause. If the enuresis is, as many feel, simply an undesirable habit 
trait from poor training, then the mechanical methods of awakening the 
child with nocturnal enuresis should be sufficient. If the enuresis is due 
to a personality disorder, then psychotherapy is indicated. However, if 
the enuresis is on the basis of an organic pathologic entity, whether that 
be inherited, congenital, or acquired, the entity must be found and treated, 
not only to relieve the child of his immediate problem, but to prevent per- 
manent or longstanding damage to the urinary tract. 

The authors do not believe that all enuretic children, or all enuretic 
female children, necessarily have organic disease. However, they are 
of the opinion that a rather high incidence of urethral and bladder disease 
will be found if these children, whose primary admission symptom is 
enuresis, are completely studied. In the past, the parent and the doctor 
have been reluctant to submit an enuretic child to a complete urological 
workup which would perhaps involve pain and an anesthetic. With modern 
cystoscopic instruments, advances in anesthesia, and improved urographic 
media, the problems of a complete urological examination have been min- 
imized. 

The authors found the incidence of organic disease to be much higher 
than that reported by most contributors, possibly because only refractory 
enuretics, or those with pyuria, have been referred to them by a number 
of pediatric clinics, with no way of ascertaining the total number of enure- 
tics seen by those clinics, nor the percentage of their refractory cases 
seen. 

The authors limited the discussion to female enuretic children treated 
in their clinic during a 2-year period because each case appeared to fol- 
low a similar pattern. The commonest lesion found was a narrow urethra, 
with resultant edema of the bladder neck, low-grade chronic trigonitis, 
and in many, the bladder had become trabeculated in order to overcome 
the narrow urethral outlet. These findings are not peculiar to enuresis. 
Recently, a number of articles have been published drawing attention to 
similar findings in female children as the cause for chronic recurring 
infections. The authors believe that a definite relationship exists between 
the problem of the refractory enuretic child and the child with recurrent 
urinary tract infections. The treatment is similar, i. e., the eradication 
of infection and the dilatation of the urethra as many times as is indicated 
along with bladder dilations when indicated. The use of banthine or other 
antispasmotic drugs, along with local treatment of the urethra and bladder, 
will undoubtedly result in the highest percentage of cures of these com- 
bined problems. 

During the past 2 years, 19 female children, ranging in ages from 
3-1/2 to 10 years, have been referred with the primary problem of enure- 
sis. Of this group, 17 had nocturnal enuresis only, and 2 had both noc- 
turnal and diurnal enuresis. Eighteen had been enuretic since birth and 



Medical News Letter, Vol. 25, No. 2 



19 



one had become enuretic following measles 6 months prior to examination. 
Seven had no complaints other than enuresis, 9 had recurrent cystitis, 2 
had recurrent cystitis and pyelonephritis, and one was seen in acute uri- 
nary retention. 

Excretory urograms and panendoscopic examinations were performed 
on each of these children as soon after the first visit as was compatible 
with the state of any infection present. The results of the excretory uro- 
grams showed evidence of chronic pyelonephritic damage to one kidney 
in 2 of the children. Bilateral renal damage was demonstrated in none. 
Panendoscopic examination revealed the pathological process in one child - 
to be a spastic bladder neck secondary to a spina bifida with damage to the 
parasympathetic innervation of the bladder. In one child, obstruction was 
found to be due to scar tissue resulting from the removal of a urethral diver- 
ticulum one year prior to her first visit to the clinic. 

In 15 of the remaining cases, urethral strictures required dilation 
with sounds before a cystoscope could be introduced. Edema and evidence 
of chronic inflammatory changes were felt to be important in 11 cases. 
In 9 cases, trabeculations were found in the bladder wall. A reduced bladder 
capacity was found in 4 of the cases with capacities of less than 100 cc. 

In all of the 19 cases referred to the authors, some pathologic entity 
was present which could account for the enuresis, and indicated the pos- 
sibility that the incidence of local organic disease as an etiologic factor 
may be much higher than previously reported. 

Treatment consisted, first, of eradication, if possible, of any infec- 
tion present, using appropriate antibiotics or chemotherapeutic agents. 
Then followed a series of urethral dilations at intervals of 1 to 3 weeks, 
depending largely on the child's response to therapy. These urethral 
dilations were carried out in all except one case without anesthesia. The 
one exception was the youngest child in the group, 3-1/2 years old. The 
children were extremely cooperative, most of them were eager to report 
on their progress and were only moderately reluctant to have the painful 

dilation performed. 

Bladder dilations to capacity were performed on the 4 children with 
small capacities under general anesthetics on three occasions each. Of 
the 19 children treated, 15 were completely relieved of their enuresis 
following urethral dilations ranging in number from two to eighteen. 
Three children had marked improvement in their enuresis, converting 
from nightly to weekly or bimonthly enuresis, and one was cured of her 
diurnal enuresis, but continued to have nocturnal enuresis. 

Those children with recurrent urinary infections were controlled, 
and with the exception of the 2 with gross anatomic lesions, their infec- 
tions were completely cured. The 2 who were not cured were kept under 
control with continued antibiotics or chemotherapeutic s, and periodic 
urethral dilations. (J. Urol., Dec. , 1954; Capt. A.C. Abernethy, MC 
USN.and LT E. M. Tomlin, MC USN, U.S. Naval Hospital, Bethesda, Md. ) 



20 



Medical News Letter, Vol. 25, No. 2 



Methanol Poisoning 

The investigation described as "An Experimental Study of the Toxic 
Amblyopias with Particular Reference to Methyl Alcohol Poisoning" was 
confined during the time of the study to methyl alcohol poisoning alone, 
and during this time a number of the objectives set, were attained. The 
object, then, of this project was first of all to find a suitable non-human 
experimental test object on which methyl alcohol poisoning could be validly 
investigated with several ultimate objectives in mind. Of these, one was 
to find the proximal toxic agent in methyl alcohol poisoning. A second 
was to investigate carefully the systemic as well as the ophthalmic aspects 
of methyl alcohol poisoning, particularly in the role of acidosis as the 
cause of death and blindness, and in regard to extraocular damage caused 
in methanol poisoning. Finally, it was desired to evaluate presently used 
therapeutic methods on the basis of the new rationale gained by experi- 
mentation, and if possible to institute additional, rational, therapeutic 
procedures. 

In attempting to find the proximal toxic agent, experiments were 
done using methyl alcohol and its known degradation products on the 
metabolism of the surviving beef retina. This short cut proved to be 
reasonably fruitful. A second approach was to follow the metabolic fate 
of administered methyl alcohol in the experimental animal. Because of 
limited quantity of C 14 labeled methanol available, the white rat was 
chosen by necessity. That this later proved to be not an ideal test object, 
did not invalidate a certain number of the results obtained, and could not 
have been avoided because of quantitative considerations. A third approach, 
the use of the primate test object, proved highly fruitful and resulted in 
establishment of a valid experimental test object for methanol poisoning, 
A fourth approach using antabuse as an adjuvant drug, and ethanol as a 
presumably antidotal drug, gave results of varying significance but bear- 
ing without question on the problem of eventual therapy. Altogether, a 
large percentage of methods employed in the approach to the problem 
gave fruitful results, and at the present time under another contract, 
are leading even further toward the ultimate goal. 

In summary, it may be said that experiments done on the surviving 
beef retina indicated unequivocally that formaldehyde was the proximal 
toxic agent in methanol poisoning. The increase in toxicity to mice after 
administration of antabuse (an aldehyde accumulating agent) added strength 
to this conclusion. Increased toxicity in mice following administration of 
ethanol, led to caution in the proposed use of this agent as a methanol 
acidote. Investigation of the rhesus monkey as a possible test object for 
methanol poisoning was highly fruitful, and with this test object, the authors 
were able to reproduce a picture of human methanol poisoning in every res- 
pect. The latent period between inebriation and severe toxic symptoms, 



Medical News Letter, Vol. 25, No. 2 



21 



the eye effects both pupillary and retinal, the acidosis, and the comatose 
death--all appear in the monkey given methanol in doses of 3g/kg or great- 
er. Experiments in which acidosis was combatted with base, showed that 
more monkeys survived this potentially lethal situation but that many went 
on to show eye symptoms and to die of central nervous system depression 
and peripheral vascular collapse in spite of total absence of acidosis. Thus, 
acidosis must be combatted, but it by no means represents the sole danger 
in methyl alcohol poisoning. The ophthalmoscopic appearance of the retina 
and its time course is distinctive in these monkeys, is reproducible at will, 
and corresponds closely to eye symptoms in those few human cases which 
have been reported accurately. The cog-wheel pupil phenomenon has been 
described for these monkeys and had not hitherto been reported in methyl 
alcohol poisoning. Thus, it is seen that many of the objectives have been 
attained. 

The authors believe that the identification of formaldehyde as the 
proximal toxic agent in methyl alcohol poisoning sets at rest a fifty-year 
controversy, and directs research along a more sure pathway for achieve- 
ment of rational, therapeutic agents. They believe that use of the dual 
test objects, the surviving beef retina, and the whole rhesus monkey, 
has allowed, and will allow, increasedly rapid progress on a valid exper- 
imental basis. This eliminates confusion which existed in this field as 
a result of using rodents and carnivores for laboratory experimentation 
in reference to human methyl alcohol poisoning. The work begun, using 
C 14 labeled methanol, must be repeated with the primate test object, and 
promises great success when employed in this manner. Similarly, thera- 
peutic agents under consideration can now be tested in an adequate fashion. 
{NR 120-017, ONR) 

$ * sje >J: sfc $ 

Lichen Planus 



Lichen planus is one of the skin diseases which presents lesions in 
the mouth, and while as a skin disease, it is relatively uncommon, con- 
stituting approximately 1% of skin cases seen in hospital out-patient de- 
partments, recent experience indicates that the oral lesions are more 
common than is generally believed. In most cases in which oral lesions 
have been seen, these are so characteristic that diagnosis is straight- 
forward, but some patients have presented lesions in the mouth with 
associated ulceration and in such cases there can be difficulty in diag- 
nosis. Lesions in the mouth in lichen planus can also superficially 
resemble areas of leukoplakia, and although leukoplakia is recognized as 
a precancerous condition, no definite relationship has been established 
between lichen planus and carcinoma so that differentiation's clearly of 
importanc e. 



22 



Medical News Letter, Vol. 25, No. 2 



The difficulties of diagnosis are increased because the oral lesions 
of lichen planus can occur without the skin lesions, and if the latter do 
occur, they may precede or follow, or appear at the same time as those 
in the mouth. 

The basic lesion as seen on the skin is a small, flat, angular papule 
which is smooth, shiny, and violaceous in color, while on the mucous 
membranes it presents as a white, pinhead papule. The clinical variants 
of the papule which result are described as obtuse (dome- shaped), verru- 
cous (a warty outgrowth), bullous (vesicular), erythematous (a soft lesion 
which is crimson in color), and atrophic (white spot), and all of these var- 
iants appear to have the same basic pathology as the simple papule. Some 
variants are more rare than" others, but each may occur independently 
or in association with the simple flat angular papule which is the common 
skin lesion. The arrangement of papules may be discrete and haphazard, 
or in a linear or circular pattern. 

Skin lesions may be found on any part of the body but are most common 
on the flexural aspects of the forearms and wrists, and the inner surfaces 
of the knees and thighs, together with the skin over the lumbar spine. 
Rarely, the nailbeds may be affected, and then the papules are visible 
through the transparent nail, while softening of the nail with grooving and 
ridging of the surface may result from enlargement of the papule. 

In the linear arrangement of papules, the distribution of the skin 
lesions is considered by some to be associated with the course of a nerve, 
while with some patients a linear grouping of papules is said to be provoked 
by making a scratch mark along the skin. In the annular distribution, the 
papules are seen in a circular group, having apparently normal tissue 
within the circle. 

Patients usually complain of the skin lesions being "itchy", and in many 
cases the itching is said to be intense. 

The essential features of the form of the disease, as it is found in the 
mouth and on the skin, are the same and vary only in the site and structure 
of the lesions. Moisture and trauma modify the appearance of lesions in 
the mouth, and in cases with associated ulceration, secondary infection 
may further distort the clinical picture. The result is that lesions seen 
in the mouth are less easily recognized than those on the skin and are, 
therefore, more difficult to diagnose. 

The initial lesion in the mouth is a white papule, the size of a pinhead, 
conical or flattened in shape, and the surrounding mucous membrane may 
be normal or show varying degrees of inflammation. Ulcers having a 
raised yellowish base are said to occur and to be extremely painful, while 
cases have recently been seen of lichen planus of the mouth with associated 
chronic ulceration and are considered to be more frequent than hitherto 
reported. Where the bullous form occurs, vesicles may be seen on occa- 
sion in the early stages, but these rapidly break down in the mouth, becom- 
ing ulcerated and sore. 



Medical News Letter, Vol. 25, No. 2 



23 



By coalescence of numbers of the pinhead white papules, plaque-like 
lesions may be formed, but beyond these plaques, individual white papules 
are usually found, and these greatly assist in the diagnosis of the lesion. 
The most characteristic form of lichen planus seen in the mouth is that 
in which the papules form a white lacelike network on the mucosa with 
thickened nodules at the intersections of the striations composing the net- 
work, while at the periphery of these nodules, white striae may be seen 
radiating in stellate fashion. Groups of papules may also aggregate to 
present a white striated appearance, or by a circular grouping, present 
the so-called annular form. 

The white papules, and especially the network formation, are common- 
ly found on the buccal mucosa, and particularly on the mucosa related to 
the plane of. occlusion. On the tongue some early lesions are said to reveal, 
on close inspection, a fine network in which the meshes are occupied by the 
filiform papillae. 

As the exact etiology of the disease is unknown, treatment is largely 
empirical. General treatment, which is almost universally accepted, con- 
sists of measures to increase the patient's general health. These include 
attention to hygiene, a plain diet, and where possible, freedom from anxiety. 
Eradication of focal infection, dental or otherwise, should form part of the 
tr eatm ent. 

Drugs, bacterial antigens, and radiotherapy have all been used empiri- 
cally in the treatment of the disease. Many cases improve with no treat- 
ment, and some recur even after apparently successful treatment. In view 
of the influence of anxiety, which is noted in many case reports, the effects 
of suggestion in the various forms of treatment cannot be discounted. It 
is not possible to define any standard form of treatment, which must await 
a better understanding of the etiology of the disease. (Oral Surg., Dec., 1954; 
A.I. Darling, M. D. S. , and H. S. M. Crabb, M. D. S. , Bristol, England) 

:{c $ 3je ijs iff $ 

American College of Chest Physicians 

The American College of Chest Physicians will present the 8th Annual 
Postgraduate Course on Diseases of the Chest at the Bellevue-Stratford 
Hotel, Philadelphia, Pa., 7-11 March 1955. 

Medical officers interested in attending the above course should for- 
ward official requests to the Chief of the Bureau of Medicine and Surgery. 
Authorization orders only can be provided. However, the $75.00 registra- 
tion fee will be reimbursed to those approved for attendance. Detailed 
information on the content of the course may be obtained from the American 
College of Chest Physicians, 112 East Chestnut Street, Chicago, 111. 
(ProfDiv, BuMed) 



>!< >r >n n~ & 



24 



Medical News Letter, Vol. 25, No. 2 



"Just One Letter " 

With the approval of the Surgeon General and the writer, the following 
personal letter is quoted. Perhaps there are others whose reactions are 
the same. 

I am taking the liberty of writing this letter to say 'how 
right you are ! 1 

On a number of occasions - -both orally and in writing- -you have 
pointed out the advantages : personal, professional, and financial, 
that are a part of the Navy way of life. 

In the past, 1 took all of these for granted, but having recently 
resigned to enter private practice, I can testify forcefully to 
the correctness of your views and your position. You are 
absolutely right! 

On the personal side is the rewarding feeling that comes with 
being a member of the Navy team. 

On the professional side comes the satisfaction that accrues to 
the physician who can practice good Medicine unencumbered by 
the economics of private practice. And the occasional transfer 
to a new job is a stimulating challenge which tends to keep one 
out of the proverbial rut. 

And, finally, on the financial side the Navy Medical Officer does 
O. K. Having resigned after twelve years of active duty, I 
estimate this has cost me in the neighborhood of a $100,000 
annuity retirement policy. Parenthetically, this financial loss 
I can never make up. 

Of course, as in any other walk of life, there are disadvantages, 
too, to Service life; but I can honestly say the rewards far out- 
weigh them. I sincerely regret leaving the Navy, and wish I 
were back on the "Team". 

I am proud of my twelve years of association with the Navy Medical 
Department. In my book, you are the finest. I hope you continue 
to spread the 'word', because you are so right! " 



****** 



Medical News Letter, Vol. 25, No. 2 



25 



Training Course in Special Weapons, Isotopes , 
and Mi litary Medicine for Reserve 
Medical and Dental Officers 

The fourth annual course, "Special Weapons, Isotopes and Military 
Medicine, 11 will be sponsored by the Inspector, Naval Medical Activities, 
Pacific Coast, and presented by the Commandant, Twelfth Naval District, 
during the period 28 February - 4 March 1955, at the U.S. Naval Station, 
Treasure Island, San Francisco, Calif. 

This course has been arranged to provide Reserve Medical Depart- 
ment officers of the Armed Forces the latest information to be employed 
in the many and varied aspects of special weapons, isotopes, and military 
medicine and dentistry. Each subject will be presented by a speaker of 
prominence in the specialty concerned. 

Eligible Reserve officers will receive retirement point credits, on 
the basis of one(l) point for each day of attendance. Reserve Medical 
Department officers desiring point credits for attendance must obtain 
authority and appropriate orders to assure accreditation. Officers who 
hold appropriate duty orders, and a limited number of officers in the 
Active Status Pool, may be issued orders to active duty for training with 
pay. A tentative program and applications for active duty training and/or 
authorized orders will be mailed prior to 1 January 1955. 

Naval Reserve Medical Department officers who have performed 
fourteen (14) days active duty for training, with or without pay; retired 
officers; or officers on the Inactive Status List are invited to attend this 
course without orders and will not receive retirement point accreditation. 

Although this course is intended primarily for Naval Reserve Med- 
ical Department officers of the Pacific Coast, active duty personnel are 
invited to attend, as well as other components of the Armed Forces, the 
Public Health Service, and Civil Defense personnel. (DMO, 12th N. D. ) 

$ sjc $ $ # * 

From the Note Book 

1. For the past four years the National Bureau of Standards has been con- 
ducting an intensive program of research and instrument development in 
high-energy x-rays ranging from 2 million to 180 million electron volts. 
This work, under the direction of Dr. H. W. Koch, Chief of the Bureau's 
Betatron Section, is providing basic data essential to the safe and effec- 
tive utilization of the radiations from high-energy electron accelerators 
in medical treatment, industrial radiography, and nuclear physics re- 
search. 

In the course of the program, radiation from the Bureau's 50-million 
volt betatron and 1 80-million- volt synchrotron has been used to probe the 



26 



Medical News Letter, Vol„ 25, No. 2 



atomic nucleus, and, thus, valuable information about its internal structure 
is being obtained. Development of a crystal spectrometer for selecting 
radiation of a particular energy has opened the door to many research 
problems formerly considered impossible. Studies have been made of 
the distribution and absorption of high-energy x-rays in a material sim- 
ulating the body of a patient; direct visual techniques have been worked 
out for detecting faults and flaws in metallic structures; recommended 
practices have been developed for the protection of operating personnel; 
and standardization and calibration procedures for high-energy x-rays 
are being set up. (NBS, Summary Technical Report 1897) 

2. Accidental exposure to high-energy x-rays, or to the electrical poten- 
tials of the high-energy generators, can be extremely serious to operating 
personnel. However, because of the newness of the field, recommendations 
for safe practices have only recently been completely formulated. This 
formulation was accomplished by the National Committee on Radiation 
Protection under Bureau sponsorship and has been published as an NBS 
handbook. Some of the recommendations in the handbook suggest suit- 
able measurement and personnel protection instruments; others deal with 
the use of energy units (ergs/cm and ergs/gram) in the measurement of 
high-energy radiations. A large part of the experimental data and calcula- 
tions in the handbook was provided by the NBS betatron laboratory. (NBS, 
Summary Technical Report 1897) 

3. A method of measuring variety of clinical experience which small hos- 
pitals offer nursing students is given in a new Public Health Service mono- 
graph issued with the December issue of Public Health Reports. 

The publication, "Appraising the Clinical Resources in Small Hospi- 
tals, " gives a simple method of gathering facts on diagnostic conditions 
in hospitals of different sizes. The article suggests that the method may 
be particularly useful to nursing schools in deciding whether to include 
small community hospital experience in students' programs. It also is 
of interest to those concerned with planning hospital facilities and coordi- 
nating hospital programs. (PHS, H. E. W. ) 

4. The Surgeon General of the Public Health Service has announced 
approval of Federal grants for 972 medical research projects, totaling 
$10,275,533, for basic and applied research inmanyof the major diseases 
afflicting Americans today. The grants were approved during recent meet- 
ings of the seven National Advisory Councils and were scheduled for pay- 
ment as of December 1, 1954. 

Two hundred and eighty-nine of the awards, totaling $3,079,840, were 
for new research projects, and 683, totaling $7,195,693, were for continua- 
tion of existing projects. 



Medical News Letter, Vol. 25, No. 2 



27 



The awards were made to scientists in approximately 215 research 
institutions in the United States and are administered by the National 
Institutes of Health, research bureau of the Public Health Service. 
(PHS, H. E. W. ) 

5. The lowest death rate in the history of the country and the largest 
annual number of births were forecast for 1954 by the Surgeon General 
of the Public Health Service. The death rate for the year is expected to 
close at 9.2 deaths per 1000 population, a substantial drop from the rates 
of 9.6 or 9.7 which have prevailed over the past 5 years. The absence of 
any reported outbreak of influenza in .1954, with consequent, low death rates 
for the chronic cardiovascular diseases, was cited as a principal reason 
for the decline. Infant and maternal deaths were also expected to hit new 
lows. 

Births will top the 4-million mark for the first time, according to 
preliminary estimates. The expected birth rate of 25.2 per 1000 popula- 
tion is the second highest in 28 years, and only 5.3% below the peak year 
of 1947. A continuing rise in the births of third, fourth, and fifth children 
is probably responsible for the birth increases in 1953 and 1954. No in- 
crease in births of first children was expected because of falling marriage 
rates since 1951. (PHS, H. E. W. ) 

6. The California Department of Public Health reports an outbreak of 
poisoning following the ingestion of smoked bonito. Nine of 16 persons who 
ate the fish became ill with flushed face, diarrhea, headache, pain in the 
neck, chills, cramps, and an unusual sensation in the upper lip from 1 5 min- 
utes to 1-1/2 hours later. The fish were caught off the coast and were 
taken to a smoking and curing place. A similar outbreak was reported 

for the week ended December 4. As a result of these outbreaks,' an 
attempt is being made to determine the source of illness following the con- 
sumption of this type of fish. 

The Los Angeles City Health Department reports 2 outbreaks of gastro- 
enteritis among patrons of 2 restaurants. No food was available at either 
place for bacteriological examination, but pot roast and hollandaise sauce 
were suspected of being the vehicles of infection. At one restaurant, the 
meat for the pot roast was received 2 days prior to its use and was kept 
in a walk-in icebox. Ten pieces of meat were roasted. As the meat was 
needed, it was sliced and placed on a steam table. However, the meat 
for a party of 16 was served directly on the plates. Of these, 10 became 
ill from 10 to 15 hours later. The sauce at another restaurant was pre- 
pared at 5:30 p.m., and was kept on a shelf near the steam table. Of a 
group of 1 1 persons who ate at 9:30 p.m., 6 became ill about 4 hours 
later. 

Dr. W.R. Giedt, Washington State Department of Health, reports an 
outbreak of gastro- enteritis among persons who ate ham and turkey dinners. 



28 



Medical News Letter, Vol. 25, No. 2 



The ham was boned at the butcher shop where it was purchased. Both 
the ham and the turkey were cooked in a private home. The ham was 
then taken to the butcher shop for slicing. Both meats were left at room 
temperature until the next day, and were served in sandwiches in the 
afternoon and as sliced meat at 6:00 p. m. Eight persons became ill with 
severe vomiting, diarrhea, and prostration from 1 to 1-1/2 hours later. 
Because of the pattern of food intake and illness, it is believed that ham 
was the probable vehicle of infection, and that the turkey was contaminated 
from it, either in handling or en route to the laboratory. Gram -positive 
micrococcus having characteristics of toxigenic staphylococcus was found 
in specimens of both the ham and the turkey. (PHS, H. E. W. ) 

7. The results of 365 corneal grafts, performed at the Manhattan Eye, Ear 
and Throat Hospital, are analyzed by the author for further light on the 
results of keratoplasty. (A.M. A., Arch. Ophth., Dec, 1954; R. T. Paton, 
M. D. ) 

8. The diagnosis of rheumatic heart disease requires recognition of the 
etiology of the process and evaluation of myocardial, endocardial, and 
pericardial lesions, as well as of possible lingering activity of the rheu- 
matic process. (Am. J. Med. , Dec., 1954; A. A. Luisada, M. D. ) 

9. Clinical and autopsy records of 100 cases of aortic stenosis, without 
significant involvement of other valves, were reviewed. It was concluded 
that aortic stenosis, even when severe, may be accompanied by few, if 
any, of the classic signs. Assessment of the degree of aortic stenosis 
by the usual clinical criteria is difficult. (Arch. Int. Med., Dec, 1954; 

J. Bergeron, M.D., W. H. Abelmann, M.D., H. Vazquez-Milan, M. D. , 
and L. B. Ellis, M. D. ) 

10. Practical factors in gastric resection are discussed in Am. J. Surg., 
Dec, 1954; M. B. Noyes, M. D., andC.H. Lithgow, M. D. ) 

11. A report describing some of the more common errors made in recog- 
nizing and treating diseases of the heart appears in Circulation, Dec, 1954; 
R.B. .Logue, M. D. , and R. W. Hurst, M. D. 

12. The pathology of 7 cases of Wegener's granulomatosis presenting severe 
destructive lesions of the respiratory tract, arteritis, and nephritis, is des- 
cribed. (Arch. Path., Dec, 1954; G. C. Godman, M.D.,andJ. Churg.M. D. ) 

13. A review of the history and modern literature of splenosis (autotrans- 
plantation of splenic tissue) appears in Arch. Surg., Dec, 1954; Capt. 
E.A. Cohen, MC USA) 



Medical News Letter, Vol. 25, No. 2 



29 



Board Certifications 

Ameri can Board of Ophthalmology 
LT T. N. Kirkland (MC) USN 
CAPT E.C. Swanson (MC) USN 

American Board of Otolaryngology 
LCDR J. B. Dominey (MC) USN 

American Board of Pathology 

LT S. D. Kustermann (MC) USN 

A merican Board of Pediatrics 
LT R.F. Neal (MC) USNR 

American Board of Psychiatry and Neurology 
LT H. Trosman (MC) USNR 

American Board of Surgery 

LT J. A. Barss (MC) USNR 

LT L. W. Nowierski Jr., (MC) USN 

LT N. B. Thomson Jr., (MC) USNR 

Associate American College of Medicine 
LT R. Foulk (MC) USN 
LT JG W. R. Hansen (MC) USNR 
CAPT E.C. Keimey (MC) USN 
LT A. M. Margileth (MC) USN 
LCDR F.M. Morgan (MC) USN 
LT R. W. Sharp (MC) USN 

$ $ $ ajs age $ 

Correction 



In Vol. 24, No. 12, page 17, the credit line for Fluorides in Water 
Supplies should read: J. H. Shaw, School of Dental Medicine, Harvard 
University. 



# # jji # 5[C # 



30 



Medical News Letter, Vol. 25, No. 2 



BUMED NOTICE 6310 7 December 1954 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical Personnel Regularly 
As signed 



Subj: BUMEDINST 6310. 3 CH 4 {Instructions and definitions relating to 
certain diagnostic titles, Individual Statistical Report of Patient, 
and Morbidity Report), and notice of reporting requirement for 
submission of a NAVMED-F card for each patient "Continued as 
of 31 December 1954" 

Encl: (1) Subject change 

This notice provides replacement pages 7, 14, 26a, and 27 for enclosure 
(I) of BUMEDINST 6310. 3 and (2) to remind addr essees of the requirement 
of submitting a NAVMED-F card on each patient "Continued as of 31 Decem- 
ber 1954. " 

5ft * * * * * 

BUMED INSTRUCTION 7302. 3 14 December 1954 

From: Chief, Bureau of Medicine and Surgery 

To: All Activities Under the Management Control of BUMED 

Subj: Change orders to NOy contracts; citation of funds after close 
of the fiscal year 

Ref : (a) NavCompt Manual Volume 2, paragraph 022083 

(b) NavCompt Manual Volume 3, paragraphs 032002 and 032005 

This notice informs addressees of their responsibility in connection with 
the citation of funds on change orders to NOy contracts. 

****** 

BUMED NOTICE 6320 15 December 1954 

From: Chief, Bureau of Medicine and Surgery 
To: All Naval Hospitals Except Bethesda 

Subj: Completion of Part IV of the Hospital Staffing Report 
(NAVMED-1353) for the month of January, 1955 



Medical News Letter, Vol. 25, No. 2 



31 



This notice brings to the attention of addressees the provisions set forth 
in Part IV, paragraph 1, Section II of BUMEDINST 6320. 15 which requires 
completion of Part IV of the Hospital Staffing Report (NAVMED- 1 353) for 
the month of January. 

****** 

BUMED NOTICE 6320 16 December 1954 

Fiom: Chief, Bureau of Medicine and Surgery 
To: All Naval Dispensaries 

All Continental Stations Having Infirmaries and Dispensaries 

Subj: Completion of Part II of the Staffing Report (NAVMED- 1 357) 
for the month of January 1955 

This notice brings to the attention of addressees the provisions Set forth 
in subparagraph 5b of BUMEDINST 6320. 16, which requires completion 
of Part II of the Staffing Report (NAVMED- 1357) 
for the month of January. 

****** 

BUMED INSTRUCTION 6320. 5D 21 December 1954 

From: Chief, Bureau of Medicine and Surgery 
To: All Naval Hospitals 

Subj: Naval hospitals designated to receive patients who require special 
treatment 

Ref: (a) Article 11-30(2), Manual of the Medical Department 

This instruction designates certain naval hospitals to receive patients who 
require definitive treatment and specialized medical care. The designa- 
tions are in accordance with missions to be incorporated in Tentative 
Basic Naval Establishment Plan, Fiscal Year 1956. 

BuMed Instruction 6320. 5C is cancelled. 

****** 



The printing of this publication has been approved by the Director 
of the Bureau of the Budget, June 23, 1952. 



32 



Medical News Letter, Vol. 25, No. 2 



BUMED INSTRUCTION 6250. 4 



22 December 1954 



From: Chief, Bureau of Medicine and Surgery- 
Chief, Bureau of Yards and Docks 
To: Distribution List 



Subj: Pest control; vector (health) and economic 

Ref: (a) SECNAVINST 6250. 2 of 31 March 1953 

(b) BUDOCKSINST 5450. 8 of 12 Nov 1953 (SNDL F2, Nl, N2) 

(c) BUMEDINST 6250. 3 of 23 April 1953 

(d) SECNAVINST 6250. 1 of 25 March 1953 (all shore stations) 

(e) BUMEDINST 4210. IB of 8 June 1954 

Encl: (1) SECNAVINST 5420. 17 of 13 Nov 1953 (with encl. ) 

(2) Pest Control Responsibilities of Medical and Public Works 
Offic er s 

(3) Availability of Pest Control Personnel 

This instruction establishes policies for the achievement of maximum 
efficiency and safety in the control of pests and implements the provisions 
of enclosures. 



The special training and experience of the medical officer equip him 
to render an important service in reducing the incidence of automobile 
accidents . 

The statistics for the Navy and Marine Corps for 1952 showed that 
the number of deaths totaled 675, with 8000 admissions to the sick list. 



j[t j{s >{e 5jc S{t $ 




Medical Department Participation in the Motor 



Vehicle Accident Reduction Program 



Medical News Letter, Vol. 25, No. 2 



33 



An average of 46 days was required for treatment in each case. Over 80% 
of the accidents with injuries and deaths occurred on leave or liberty, and 
in 4 out of 5 cases in a privately owned passenger vehicle. Accidents 
happened mostly on holidays and weekends, and the persons involved usually 
were in the age group under 30. About twice as many deaths were caused 
by accidents as were caused by all diseases during the year. 

The figures at a typical Naval Air Station having a military population 



of approximately 15, 000 were as follows: 

1. Total number of personnel involved in accidents 1100 

2. Total number of auto accidents 407 

3. Total number of accidents resulting in casualties 160 

4. Total number of personnel killed or injured 297 

5. Total number of deaths 15 



Action Taken. In February 1952, the Chief of Naval Air Technical 
Training at the Naval Air Station, Memphis, Tennessee, established a 
permanent Board of officers, now generally known as a "Safe Driving 
Council, " and charged them with the responsibility of studying the problem 
of motor vehicle accident prevention in privately owned vehicles and making 
recommendations to the commanding officer to reduce them. In addition, 
the Safe Driving Council was authorized to proceed with a program of educa- 
tion, using all media designed to accomplish the objectives of the program, 
audio and visual. In general, the problem was attacked on four fronts, mainly: 
education, enforcement, traffic engineering and administrative action. Fol- 
lowing is a short discussion of approaches used in each field: 

1. Education. 

Education is a most important deterrent to accidents generally. Effort 
is made to develop an attitude of "safety consciousness, " as opposed to ari 
attitude of recklessness and willingness to take chances. There is adequate 
evidence to support the contention that attitudes can be changed, and educa- 
tion is, perhaps, the most effective instrument. Following are some of the 
forms of education which were used at the Naval Air Station, Memphis, in 
promoting the safety program : 

Indoctrination of incoming drafts of trainees. 
Automobile movie "shorts" on automobile safety. 

Use of pledge cards and club cards to encourage identification with 
the program. 

Support of the automobile safety program by the station newspaper, 
"Bluejacket. " 

2. Enforcement. 

Enforcement is the most obvious approach to automobile safety and, 
undoubtedly, is the most effective means of producing early results. How- 
ever, the permanency of this method depends on continued application, and 
it is doubtful that driver safety consciousness is retained in any appreciable 
degree after the threat of punishment is removed. A patrol on the highways 



34 



Medical News Letter, Vol, 25, No. 2 



approaching the station during liberty hours was inaugurated, in coordina- 
tion with the civilian highway patrol program, in a joint effort to maintain 
observance of traffic laws. There is no doubt that this measure was effec- 
tive. A close liaison was maintained with the state and county traffic 
authorities in a concerted effort to assist the local civilian agencies in 
solving enforcement problems. It was requested that reports of all traffic 
violations coming to the knowledge of the enforcement agencies in the com- 
munity be forwarded to the local station authorities. In this way, proper 
disciplinary action could be taken locally when required, and note of addi- 
tional accidents added to the compilation of statistics. 

3. Engineering. 

Under this approach to the problem, one of the first items was the 
maintenance of "pin" maps of the location of accidents in order to discover 
specific danger areas. Action of a specific nature was then possible. 

A number of recommendations concerning traffic engineering, such 
as stop signs, traffic lights, traffic lanes, lining of pavement, routing of 
traffic, et cetera, were made by the Safe Driving Council. In general, the 
possibilities of making extensive improvements through traffic engineering 
are doubtful due to the costs involved. However, in long range planning, 
traffic engineering must not be neglected. 

4. Administrative Action. 

Military organizations in general have a special control over the indi- 
viduals under their command which permits reduction of accidents by the 
simple expedient of restriction of automobile travel. This may be obtained 
by prohibition of automobiles on the station, by restriction of liberty, or 
by substitution of other means of transportation considered safer than the 
automobile. All are examples of approach to accident control through 
administrative action. 

Perhaps the most important step in organizing a safety program is 
the establishment of the Safe Driving Council. The Council should be com- 
posed of individuals aboard the station having an interest in automobile 
safety. Naturally, the medical officer represents the commanding officer's 
interest in conservation of his personnel and is one of the key members. 
It is advisable also to have as members officers representing the depart- 
ments of safety engineering, public information, security, administrative 
officer of the command, and transportation, as well as any specially 
trained and qualified individuals who may be available, such as psycholo- 
gists or statisticians. The enlisted body should also be represented on the 
Council as enlisted men represent the principal group of individuals on 
whom control measures are being focused. The Council functions as a 
group discussion unit, and, to some extent, as an executive body within 
limits prescribed by the commanding officer. 

5. Role of Statistics. 

One of the important steps in determining the fields of accident control 
exists in assembling statistics on information which the safety program 



Medical News Letter, Vol. 25, No. 2 35 



needs for efficient operation. Statistics provide facts concerning the 
number of accidents at various locations, the cost of accidents, their 
causes, and the number of resulting casualties. These facts play an im- 
portant part in the formulation of sound accident prevention policies. 
This information helps to state the automobile safety problem in specific 
terms and frequently suggests remedial action. Statistics also play a 
major role in the evaluation of the effectiveness of the automobile safety 
program, particularly applicable at the present time when cost conscious- 
ness receives so much emphasis. Of course the most important costs of 
all, the cost in lives and the cost of disabling injuries, are difficult to 
measure. Where statistical analysis is not possible, to a full degree, 
controlling action may be taken on the basis of statistics, available at com- 
mand, which have a similar pattern of personnel and geographic location. 

At the Naval Air Station, Memphis, an accident reduction program 
based on principles outlined in preceding paragraphs reduced the number 
of accidents by 72, casualties by 52, and material costs by $47, 000, in 
comparison with 1951 figures. In 1953, through continuation of the safety 
program, a similar reduction was effected below 1952 figures. 

6. Particular field of action available to a medical officer attached 
to a Naval, Marine, or other similar military base . 

It is said that safety is everyone's business. Surely the medical man 
and the medical department has as great a concern as any other department 
in the reduction of injuries and deaths due to automobile accidents. In the 
final analysis, it is in the field of education that the greatest permanent 
reduction in automobile accidents can be obtained. Here the medical officer 
may accept a very important role with his background and experiences in 
teaching first aid, hygiene, and other related medical subjects. There are 
certain other areas also where he has special qualifications that he can use 
to best advantage as a member of the local Safe Driving Council. 

a. The study of presence of accident-prone factors in the local en- 
vironment. 

This should include, not only study of actual accident proneness of 
individuals, but consideration of the factors present in life aboard the com- 
mand which predispose to automobile accidents, such as geographical 
location, lack of recreational facilities, abuse of liberty, drinking while 
driving, undertaking excessively long trips with attendant fatigue, or a 
general attitude of carelessness, or lack of sufficient knowledge of the 
danger involved in inexperienced operation of a motor vehicle. 

b. Physical Standards. 

Under this category is included a check on the adequacy of the 
physical standards for driving in a particular area as well as any physical 
or mental factors which are predisposing to involvement in accidents re- 
lated to duty performed, and other related factors. A medical officer is 
best able to judge whether or not accidents are being increased by exhausting 
mental or physical factors in the working or recreational environment. 



36 



Medical News Letter, Vol. 25, No. 2 



c. The problem of the drinking driver, the problem of dozing 
while driving, and that of mental or emotional instability, are all within 
the special interest of the medical officer. He is in the most favorable 
position to assemble data on such factors as the relation between blood 
alcohol level, as shown by Bogan's test or breathing test, and the inci- 
dence of accidents or the severity of injuries. Such information, as ob- 
tained, may be useful in the educational program. 

d. The medical officer is the one person who has first hand 
knowledge of every auto accident casualty. He is also best qualified to 
study the type and degree of injuries which result, and to suggest possible 
ways in which their severity may be minimized. 

e. The entire problem is so oriented around the medical depart- 
ment that it is difficult to see how personnel of any other department could 
be more concerned. A particular field in which the medical officer is ex- 
ceptionally well qualified is that of influencing men through lectures and 
admonition toward safety-mindedness. In past years, medical officers 
have devoted long hours to instruction in first aid, in personal hygiene, 
and in the prevention of venereal disease--all time well spent. There 

is no other field of endeavor in which such savings of life, limb, and 
collateral costs can be effected as in the effort to reduce automobile 
accidents. 

f. In summary, the medical department is a key unit in the pro- 
motion of an automobile accident reduction program. The medical officer 
is charged by regulation with the responsibility of representing the com- 
manding officer in protecting the health of the command. There is no 
other department so interested as the medical department in the problem 

of motor vehicle accidents. While traffic accident prevention is a "command" 
problem, the medical officer should assume a principal responsibility. The 
medical officer should never regard his qualifications as so specialized 
that he can shrug the responsibility of preventing death or injury from any 
cause. (Address by Captain G. B. Ribble (MC) USN at the Annual Meeting 
of the Association of Military Surgeons, November 29 - December 1, 1954) 

m 

SgC 3$C S|C S$C 3jC iji 

Film - Drive Right 

Film MN-7498b, "Industrial Health and Safety - Drive Right" is recom- 
mended as an outstanding film to be shown to naval personnel as part of the 
program designed to combat the steadily rising incidence of motor vehicle 
accidents. 



;|; 5j: 



Medical News Letter, Vol, 25, No. 2 



37 



General Sanitation 

Impro per Use of Coffee Urns 
fo r Dispensing Bulk Milk 

A special epidemiological report of a recent outbreak of gastroenteritis 
among personnel on a naval station attributed the outbreak to the continued 
use of a coffee urn for dispensing milk on general mess, despite the fact 
that a warning had been issued concerning the hazard involved. 

A thorough inspection of the facilities of the general mess, showed 
that the faucets of coffee urns do not admit of proper cleansing. The 
faucet, tubes, and interior of the urns, it was revealed, contained heavy- 
deposits of milk curd and milk stone. 

Bacteriology counts were taken from the urns used to dispense milk, 
and, after incubation for 18 hours at 37 degrees Centigrade, the plates 
showed unidentified colonies too numerous to count. 

It has been recommended that, if bulk milk must be served on the gen- 
eral mess at the station, suitable refrigerated dispensers be used. (Note: 
A BuMed instruction will be released in the near future, setting forth a 
sanitation program for milk and milk products, including sanitary require- 
ments for bulk milk dispensers. ) 

Co mmercially Prepared Sandwiches 

Recently reported outbreaks of gastroenteritis emphasize the hazards 
of commercially prepared sandwiches. Following investigation of one out- 
break aboard ship, traced to commercially prepared sandwiches sold at 
the soda fountain, the comments excerpted below were made by Preven- 
tive Medicine Unit No. Two: 

"Sandwiches, which had been supplied to the ship previous to the onset - 
of cases by a local civilian establishment, were cultured, and both alpha 
and beta streptococcus were found. Sale of sandwiches made by this con- 
cern was stopped at once to all naval activities. 

" Members of this Unit have been concerned about the proper handling 
of packaged sandwiches ever since the recent bacteriological examination 
of a certain packaged sandwich, prepared and offered for sale without re- 
frigeration, revealed large numbers of gram-positive cocci. This Unit 
recommends that prepared sandwiches be stored at a temperatur e below 
50°F. at all times prior to sale." 

The general principles of food service are applicable to sandwiches 
the same as to any other food, and more than 4 hours cumulative exposure 
to temperatures above 50° F. during preparation, delivery, and serving, 



38 



Medical News Letter, Vol. 25, No. 2 



renders them unacceptable for human consumption. Inspection of source, 
a knowledge of delivery channels, and inspection at the dispensing unit are 
as necessary as for other foods. Because packing sandwiches on traTys or 
in boxes prior to placing them in refrigeration will probably result in slow 
cooling due to the excellent insulating properties of bread, particular 
caution should be observed that materials are chilled prior to use, and 
that individual sandwiches are returned to refrigeration as soon as they 
are made. 

The safest policy is to ensure that not more than 4 hours (preferably 
not more than 2 hours) elapse between the time of preparation and the time 
of consumption. 



****** 



Enteric Carriers - Survey of Four Naval Vessels 

Preventive Medicine Unit No. Two reported the results of a survey of 
enteric carriers which was conducted on four naval vessels in the Norfolk 
Area. 

Rectal swabs were obtained from 331 persons. Paracolobactrum were 
noted in 61 individuals: P. coliforme in 32; P. inte rmedium in 16; and 
P. aerogenoides in 13 persons. 

Shigella flexneri was recovered from a hospital corpsmari, third class. 
During a recent Mediterranean cruise, this man had had two episodes of 
diarrhea for which only symptomatic treatment had been given. During 
the survey a course of Terramycin was administered to him, after which 
the organism could no longer be recovered. 

Attention was called also to the frequency with which water samples 
were being found to be positive for coliform organisms. Recheck showed 
the water to be free of such organisms in many instances. Such errors, 
for the most part, are due to improper collection of the sample. In this 
regard, the attention of personnel collecting water samples is directed to 
Articles 2, 14, and 19 of the Preventive Medicine Laboratory Methods 
Manual, dated July 1953. 



****** 

Testing for Chlorine Residual s 
in Shipboard Water Suppli es 

Recently, personnel of Fleet Epidemic Disease Control Unit No. Two 
investigated the potable water supply an all U.S. ships in a foreign port. 
When not distilling water at sea, the ships were obtaining their water from 
foreign shore sources. The chlorine residuals in the water of most ships 



Medical News Letter, Vol. 25, No. 2 



39 



were negative or ineffectively low. Many ships did not have chlorine test 
kits and personnel responsible were merely guessing at the residuals. In 
some instances they did not know how to chlorinate properly. 

To ensure a safe water supply, ships loading water from shore sources, 
water barges, or other ships, should perform tests for chlorine on each 
supply of water received aboard. Personnel responsible should perform 
tests for chlorine in accordance with the methods prescribed in the Preven- 
tive Medicine Laboratory Methods Manual. Procedures for the chlorination 
of water supplies are outlined in Chapter 6, Manual of Naval Hygiene and 
Sanitation. 

Requests for the Preventive Medicine Laboratory Methods Manual, 
Naval Medical School, July 1953, should be submitted on form NAVEXOS- 
158 (3-50), Stock Form and Publication Requisition, to appropriate Publica- 
tion and Printing Offices. Chlorine test kits have the following stock number 
and title: 6630-417-0000 Comparator, color, chlorine. 

$ (jt if S?S 5j= $ 

Insect and Rodent Control 

Insecticides, Pesticides, and Dispersal Devices 

Administrative inspections of SERVPAC ships reveal that chlordane 
and other insecticidal agents are being indiscriminately used without auth- 
ority and in disregard of current directives. The most prevalent errors 
noted in the use of insecticides are: (1) use^of chlordane solution as a 
space spray; (2) application of insecticides at intervals inconsistent with 
requirements for adequate control; (3) use of highly toxic insecticides 
or those contained in a combustible solvent in confined or poorly ven- 
tilated spaces; and (4) stowage of insecticides in food preparation and 
messing spaces. 

Basic precautions in the use of insecticides are set forth in paragraph 4 
of BuMed Instruction 6250.3 and, regardless of the insecticide used or safety 
claim of manufacturer, such precautions must be continuously observed. 
Personnel using insecticides are urged to become familiar with that instruc- 
tion in order to ascertain the appropriate insecticide for each specific pest 
problem. Insecticide technology has advanced so rapidly during recent years 
that it has exceeded to a considerable degree the accumulation of toxicologi- 
cal knowledge on the possible chronic effects of many new materials. The 
relative safety and widespread use of DDT, even by untrained personnel, 
has resulted in a lack of adequate respect for the hazards of certain other 
insecticides. The possibility of danger from insecticides, as with other 
chemicals, will largely depend as much on the method and condition of use 
as on the inherent toxicity of the insecticide. Usually the toxic properties 



40 



Medical News Letter, Vol. 25, No. 2 



of the solvent or carrier, as well as those of the insecticide, must be 
considered. 

SecNav Instruction 6250. 2 prohibits the procurement of nonstandard 
proprietary pesticides and dispersal devices except as noted therein. Un- 
controlled use of new pesticides having unknown toxicological effects may- 
result in serious poisoning or may even prove fatal to operating personnel 
not familiar with the necessary precautions required in their use, A man- 
ufacturer's claims of safety and effectiveness, often the basis on which an 
item is procured, in many instances are found later to be invalid. Enclqsure 
(1) to SecNav Instruction 6250.2 states the policy with respect to use of vapor- 
izing devices on naval ships and stations and avers that these devices are 
generally ineffective and unsafe except under restricted conditions. 

It has long been established that the most satisfactory method of insect 
control is to maintain a high standard of sanitation and environmental clean- 
liness. When insect infestations are discovered, immediate control meas- 
ures must be instituted. The type of insecticide and the method of applica- 
tion pertinent to each control operation should be determined by reference to 
BuMed Instruction 6250.3 and the Manual of Naval Hygiene and Sanitation. 
If doubt exists as to the proper control measures to be instituted, the services 
of trained pest control officers should be requested from shore activities. 
(COMSERVPAC Information Bulletin, Force Medical Section, Cumulative 
Edition 1953) 

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